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Chemotherapy alone versus endocrine therapy alone for metastatic breast cancerWilcken N, Hornbuckle J, Ghersi D
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SummaryChemotherapy alone versus endocrine therapy alone for metastatic breast cancerBreast cancer is the most common cancer in women. If the cancer has spread beyond the breast (metastatic disease), treatments include chemotherapy (anti-cancer drugs) and endocrine therapy (also known as hormonal treatment). Endocrine therapy is mainly given in cases where the cancer is determined to be hormone-responsive, that is, where hormone receptors (estrogen or progesterone receptors) are expressed in tumour cells. The aim of this review was to see if starting treatment with chemotherapy or starting treatment with endocrine therapy provides more benefit in terms of survival, response to treatment, toxicity from treatment and quality of life. Ten eligible studies were identified, eight of which provided information on response to treatment (817 patients) and six on overall survival (692 patients). Trials were generally older (published between 1963 and 1995) and small in size (median of 70 women, range 50 to 226 women) and were of modest quality. The types of chemotherapy used were reasonably conventional by today's standards, while the endocrine therapies used varied considerably. This review found that while initial treatment with chemotherapy rather than endocrine therapy might be associated with a higher response rate, the two initial treatments had a similar effect on overall survival. No single group of patients who might benefit from, or be harmed by, one treatment over the other were identified, although there was little information to address this question. Six of the seven fully published trials commented on increased toxicity associated with chemotherapy including nausea, vomiting and alopecia. Three of the seven trials mentioned aspects of quality of life but these provided differing results. Only one trial formally measured quality of life (QOL) concluding that QOL was better with chemotherapy. On this basis, no conclusions can be made as to the QOL achieved with either treatment. Accurate information about hormone receptor status is now routinely available for many women with metastatic breast cancer and hormonal treatments have improved in effectiveness in the last ten years. In women with metastatic breast cancer where hormone receptors are present, a policy of treating first with endocrine therapy rather than chemotherapy appears to be better on the basis of the trials and outcomes in this review, except in the presence of rapidly progressive disease.
This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2008 Issue 3, Copyright © 2008 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
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April 22. 2003 AbstractBackgroundBoth chemotherapy and endocrine therapy can be used as treatments for metastatic breast cancer. ObjectivesTo review the evidence and determine whether starting treatment with chemotherapy or starting treatment with endocrine therapy has the more beneficial effect on outcomes (survival, response rate, toxicity and quality of life). Search strategyThe Cochrane Breast Cancer Group Specialised Register was searched on August 31 2006 using the codes for "advanced breast cancer", "chemotherapy" and "endocrine therapy". Details of the search strategy applied by the Group to create the register, and the procedure used to code references, are described in the Group's module in The Cochrane Library. Handsearching of the proceedings of the annual meetings of American Society of Clinical Oncology (2005 to 2006) and the San Antonio Breast Cancer Symposium (2005) were also conducted. Selection criteriaRandomised trials comparing the effects of chemotherapy alone with endocrine therapy alone on pre-specified endpoints in metastatic breast cancer. Data collection and analysisData were collected from published trials. Hazard ratios were derived for survival analysis and a fixed effect model was used for meta-analysis. Response rates were analysed as dichotomous variables. Toxicity and quality of life data were extracted where present. Main resultsThe primary analysis of overall effect using hazard ratios derived from published survival curves involved six trials (692 women). There was no significant difference seen (hazard ratio: 0.94, 95%CI 0.79 to 1.12, P=0.5). A test for heterogeneity gave a P value of 0.1. A pooled estimate of reported response rates in eight trials involving 817 women shows a significant advantage for chemotherapy over endocrine therapy with a relative risk of 1.25 (1.01 to 1.54, P=0.04). However the point estimates for the two largest trials were in opposite directions, and an overall test for heterogeneity gave a P value of 0.0009. There was little information available on toxicity and quality of life. Six of the seven fully published trials commented on increased toxicity with chemotherapy, mentioning nausea, vomiting and alopecia. Three of the seven mentioned aspects of quality of life, with differing results. Only one trial formally measured quality of life, concluding that it was better with chemotherapy. Authors' conclusionsIn women with metastatic breast cancer and where hormone receptors are present, a policy of treating first with endocrine therapy rather than chemotherapy is recommended except in the presence of rapidly progressive disease. |
